MEDICARE: SPECIAL HOMES OF NEW JERSEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932659455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECIAL HOMES OF NEW JERSEY

Provider Business Mailing Address
First Line	:	74 VILLAGE GRN APT 14R
Second Line	:
City	:	BUDD LAKE
State	:	NJ
Zip	:	07828-1379
Country	:	US
Telephone Number	:	973-886-1953
Fax Number	:	973-664-1795

Provider Business Practice Location Address
First Line	:	74 VILLAGE GRN APT 10D
Second Line	:
City	:	BUDD LAKE
State	:	NJ
Zip	:	07828-1379
Country	:	US
Telephone Number	:	973-886-1953
Fax Number	:	973-664-1795

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TERRENCE MCKEON
Credential	:	M.ED.
Telephone Number	:	973-886-1953

Provider Enumeration Date	:	10/07/2016
Last Update Date	:	04/10/2018

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